Revision of failed traditional fundoplication using EsophyX transoral fundoplication. Surg Endosc. 2013;27:761-767. [PMID: 23052519 PMCID: PMC3572368 DOI: 10.1007/s00464-012-2542-7]

Robotic revision surgery after failed Nissen anti-reflux surgery: a single center experience and a literature review

BACKGROUND

The gastroesophageal reflux disease (GERD) worldwide prevalence is increasing maybe due to population aging and the obesity epidemic. Nissen fundoplication is the most common surgical procedure for GERD with a failure rate of approximately 20% which might require a redo surgery. The aim of this study was to evaluate the short- and long-term outcomes of robotic redo procedures after anti-reflux surgery failure including a narrative review.

METHODS

We reviewed our 15-year experience from 2005 to 2020 including 317 procedures, 306 for primary, and 11 for revisional surgery.

RESULTS

Patients included in the redo series underwent primary Nissen fundoplication with a mean age of 57.6 years (range, 43-71). All procedures were minimally invasive and no conversion to open surgery was registered. The meshes were used in five (45.45%) patients. The mean operative time was 147 min (range, 110-225) and the mean hospital stay was 3.2 days (range, 2-7). At a mean follow-up of 78 months (range, 18-192), one patient suffered for persistent dysphagia and one for delayed gastric emptying. We had two (18.19%) Clavien-Dindo grade IIIa complications, consisting of postoperative pneumothoraxes treated with chest drainage.

CONCLUSION

Redo anti-reflux surgery is indicated in selected patients and the robotic approach is safe when it is performed in specialized centers, considering its surgical technical difficulty.

Transoral incisionless fundoplication for recurrent symptoms after laparoscopic fundoplication

BACKGROUND

Revision of a failed laparoscopic fundoplication carries higher risk of complication and lower chance of success compared to the original surgery. Transoral incisionless fundoplication (TIF) may be an endoscopic alternative for select GERD patients without need of a moderate/large hiatal hernia repair. The aim of this study was to assess feasibility, efficacy, and safety of TIF 2.0 after failed laparoscopic Nissen or Toupet fundoplication (TIFFF).

METHODS

This is a multicenter retrospective cohort study of patients who underwent TIFFF between September 2017 and December 2020 using TIF 2.0 technique (EsophyX Z/Z+) performed by gastroenterologists and surgeons. Patients were included if they had (1) recurrent GERD symptoms, (2) pathologic reflux based upon pH testing or Grade C/D esophagitis or Barrett's esophagus, and (3) hiatal hernia ≤ 2 cm. The primary outcome was improvement in GERD Health-Related Quality of Life (GERD-HRQL) post-TIFFF. The TIFFF cohort was also compared to a similar surgical re-operative cohort using propensity score matching.

RESULTS

Twenty patients underwent TIFFF (median 4.1 years after prior fundoplication) and mean GERD-HRQL score improved from 24.3 ± 22.9 to 14.75 ± 21.6 (p = 0.014); mean Reflux Severity Index (RSI) score improved from 14.1 ± 14.6 to 9.1 ± 8.0 (p = 0.046) with 8/10 (80%) of patients with normal RSI (< 13) post-TIF. Esophagitis healed in 78% of patients. PPI use decreased from 85 to 55% with 8/20 (45%) patients off of PPI. Importantly, mean acid exposure time decreased from 12% ± 17.8 to 0.8% ± 1.1 (p = 0.028) with 9/9 (100%) of patients with normalized pH post-TIF. There were no statistically significant differences in clinical efficacy outcomes between TIFFF and surgical revision, but TIFFF had significantly fewer late adverse events.

CONCLUSION

Endoscopic rescue with TIF is a safe and efficacious alternative to redo laparoscopic surgery in symptomatic patients with appropriate anatomy and objective evidence of persistent or recurrent reflux.

Endoscopic Treatment of Reflux: A Comprehensive Review

The last decade has seen the rise of multiple novel endoscopic techniques to treat gastroesophageal reflux disease, many of which are efficacious when compared with traditional surgical options and allow relief from long-term dependence on antacid medications. This review will explore the latest endoscopic treatment options for gastroesophageal reflux disease including a description of the technique, review of efficacy and safety, and future directions.

Endoscopic approaches to gastroesophageal reflux disease

PURPOSE OF REVIEW

Gastroesophageal reflux disease (GERD) is one of the most common chronic conditions affecting adults. A substantial proportion of patients continue to have symptoms despite medical therapy, and there has been increased demand for minimally invasive GERD therapy. We will examine currently available techniques and outcomes data on endoscopic approaches to the treatment of GERD.

RECENT FINDINGS

In the last 2 years, research has given rise to more robust understanding of not only the pathophysiology of GERD but also how to better manage the various phenotypes. We are learning the ideal patient to benefit from endoscopic GERD therapy. In this review, we describe the four major endoluminal techniques for treating GERD and summarize current data.

SUMMARY

Endoscopic therapies are well positioned to fill the 'therapy gap' between medical therapy and more invasive surgical procedures.

Mind the Gap: Current Treatment Alternatives for GERD Patients Failing Medical Treatment and Not Ready for a Fundoplication

BACKGROUND

Gastroesophageal reflux disease is associated with Barrett esophagus, esophageal adenocarcinoma, and significantly impacts quality of life. Medical management is the first line therapy with surgical fundoplication as an alternative therapy. However, a small portion of patients who fail medical therapy are referred for surgical consultation. This creates a "gap" in therapy for those patients dissatisfied with medical therapy but are not getting referred for surgical consultation. Three procedures have been designed to address these patients. These include radiofrequency ablation (RFA) of the lower esophageal sphincter, transoral incisionless fundoplication (TIF), and magnetic sphincter augmentation.

MATERIALS AND METHODS

A Pubmed literature review was conducted of all publications for RFA, TIF, and MSA. Four most common endpoints for the 3 procedures were compared at different intervals of follow-up. These include percent of patients off proton pump inhibitors (PPIs), GERD-HRQL score, DeMeester score, and percent of time with pH <4. A second query was performed for patients treated with PPI and fundoplications to match the same 4 endpoints as a control.

RESULTS

Variable freedom from PPI was reported at 1 year for RFA with a weighted mean of 62%, TIF with a weighted mean of 61%, MSA with a weighted mean of 85%, and fundoplications with a weighted mean of 84%. All procedures including PPIs improved quality-of-life scores but were not equal. Fundoplication had the best improvement followed by MSA, TIF, RFA, and PPI, respectively. DeMeester scores are variable after all procedures and PPIs. All MSA studies showed normalization of pH, whereas only 4 of 17 RFA studies and 3 of 11 TIF studies reported normalization of pH.

CONCLUSIONS

Our literature review compares 3 rival procedures to treat "gap" patients for gastroesophageal reflux disease with 4 common endpoints. Magnetic sphincter augmentation appears to have the most reproducible and linear outcomes but is the most invasive of the 3 procedures. MSA outcomes most closely mirrors that of fundoplication.

Three-year clinical experience with magnetic sphincter augmentation and laparoscopic fundoplication

BACKGROUND

Magnetic sphincter augmentation (MSA) is a surgical intervention for gastroesophageal reflux disease (GERD) which has been evaluated in numerous studies and has shown beneficial effects. Long-term effectiveness data for MSA as well as laparoscopic fundoplication (LF) in patients with GERD are needed.

OBJECTIVE

The objective of this study was to evaluate the 3-year outcomes for MSA and LF in patients with GERD.

METHODS

This prospective, multi-center, observational registry study evaluated MSA and LF in clinical practice over 3 years (ClinicalTrials.gov identifier: NCT01624506). Data collection included baseline characteristics, reflux symptoms, medication use, satisfaction and complications. Post-surgical evaluations were collected at yearly intervals.

RESULTS

Between December 2009 and December 2014, 631 patients (465 MSA and 166 LF) were enrolled in the registry. Both MSA and LF resulted in improvements in total GERD-HRQL score (mean reduction in GERD-HRQL from baseline to 3 years post-surgery: MSA 22.0 to 4.6 and LF 23.6 to 4.9) and in satisfaction (GERD-HRQL satisfaction increase from baseline to 3 years: MSA 4.6% to 78.2% and LF 3.7% to 76.5%). Most patients were able to belch as needed with both therapies (MSA 97.6% and LF 91.7% at 3 years). MSA allowed a higher percentage of patients the ability to vomit as needed (MSA 91.2% and LF 68.0% at 3 years). PPI usage declined from baseline to 3 years for both groups after surgery (MSA 97.8% to 24.2% and LF 95.8% to 19.5%). The mean procedure time was shorter for MSA than for LF. Intraoperative and procedure-related complication rates (≤ 2%) were low for both therapies.

CONCLUSIONS

This 3-year prospective observational registry study contributes to the mounting evidence for the effectiveness of MSA and LF. Despite the more severe nature of GERD in the LF group, the clinical outcomes for MSA and LF were favorable from an effectiveness and safety standpoint.

Salvage Options for Fundoplication Failure

PURPOSE OF REVIEW

Gastroesophageal reflux disease (GERD) affects millions of people worldwide. Many patients with medically refractory symptoms ultimately undergo antireflux surgery, most often with a laparoscopic fundoplication. Symptoms related to GERD may persist or recur. Revisional surgery is necessary in some patients.

RECENT FINDINGS

A reoperative fundoplication is the most commonly performed salvage procedure for failed fundoplication. Although redo fundoplication has been reported to have increased risk of morbidity compared with primary cases, increasing experience with the minimally invasive approach to reoperative surgery has significantly improved patient outcome with acceptable resolution of reflux symptoms in the majority of patients. Recurrence of reflux symptoms after an initial fundoplication requires a thorough work-up and a thoughtful approach. While reoperative fundoplication is the most common procedure performed, there are other options and the treatment should be tailored to the patient, their history, and the mechanism of fundoplication failure.

Long-Term Outcomes of Transoral Incisionless Fundoplication in a High-Risk Pediatric Population

INTRODUCTION

Laparoscopic Nissen fundoplication (LNF) is the standard for surgical treatment of gastroesophageal reflux disease (GERD), but postoperative complications and pain are common in patients with severe neurological impairment (NI) and those undergoing reoperative procedures. Transoral incisionless fundoplication (TIF) is an endoscopic alternative to treat GERD. Long-term results in pediatric populations are unknown.

METHODS

Eleven patients who underwent TIF between January 2008 and September 2010 were included. A retrospective chart review was performed to evaluate long-term patient outcomes. Median follow-up was 5.6 years (range = 0.42-8.76 years).

RESULTS

Average patient age was 16.5 ± 5.1 years. Severe NI was present in 81.8% (9/11) of patients, and 63.6% (7/11) had undergone one or more prior fundoplication attempts. Overall, symptomatic reflux recurred or persisted in 54.5% (6/11) of patients. Recurrent symptoms were more common among those who had previous fundoplications than those who did not (71.4% [5/7] vs. 25% [1/4]). Four patients went on to require reoperation, including one laparoscopic Nissen and three disconnects. At last follow-up, 81.8% (9/11) of patients were still on antireflux medications.

CONCLUSIONS

This is the first report of long-term outcomes for treatment of GERD using TIF in a pediatric population. The recurrence rate was high, likely related to the fact that the population treated was extremely high risk. Recurrence was higher in patients with a prior fundoplication, perhaps identifying prior antireflux operations as a relative contraindication to TIF. Nevertheless, complications were low, and a subset of patients did receive a durable benefit from the procedure.

Transoral incisionless fundoplication for gastro-esophageal reflux disease: Techniques and outcomes

Gastro-esophageal reflux disease (GERD) is a very common disorder that results primarily from the loss of an effective antireflux barrier, which forms a mechanical obstacle to the retrograde movement of gastric content. GERD can be currently treated by medical therapy, surgical or endoscopic transoral intervention. Medical therapy is the most common approach, though concerns have been increasingly raised in recent years about the potential side effects of continuous long-term medication, drug intolerance or unresponsiveness, and the need for high dosages for long periods to treat symptoms or prevent recurrences. Surgery too may in some cases have consequences such as long-lasting dysphagia, flatulence, inability to belch or vomit, diarrhea, or functional dyspepsia related to delayed gastric emptying. In the last few years, transoral incisionless fundoplication (TIF) has proved an effective and promising therapeutic option as an alternative to medical and surgical therapy. This review describes the steps of the TIF technique, using the EsophyX(®) device and the MUSE(TM) system. Complications and their management are described in detail, and the recent literature regarding the outcomes is reviewed. TIF reconfigures the tissue to obtain a full-thickness gastro-esophageal valve from inside the stomach, by serosa-to-serosa plications which include the muscle layers. To date the procedure has achieved lasting improvement of GERD symptoms (up to six years), cessation or reduction of proton pump inhibitor medication in about 75% of patients, and improvement of functional findings, measured by either pH or impedance monitoring.

Long-term efficacy of transoral incisionless fundoplication with Esophyx (Tif 2.0) and factors affecting outcomes in GERD patients followed for up to 6 years: a prospective single-center study

BACKGROUND

Transoral incisionless fundoplication (TIF) with the EsophyX™ device creates an antireflux valve with good functional results in patients with gastro-esophageal reflux disease (GERD). The aim of this study was to assess the long-term effect of TIF 2.0 on pathological reflux and symptoms in GERD patients with daily dependence on proton pump inhibitors (PPI).

METHODS

Fifty patients underwent TIF. All underwent GERD-HRQL and GERD-QUAL questionnaires, upper GI endoscopy, esophageal manometry, and 24-h pH-impedance before and 6, 12, and 24 months after TIF, and subsequent yearly clinical re-evaluation.

RESULTS

Patients were followed for up to six years (mean 52.7 ± 19.7 months). In all, 83.7, 79.6, 87.8, and 84.4% of patients stopped or halved the PPI therapy 6, 12, 24, and 36 months after TIF. Three-year figure remained stable up to 6 years. Symptom scores off PPI were significantly lower at 6, 12, 24, and 36 months. At 6 months, Hill's grade I of the newly created valve persisted in all pre-procedure Hill's grade I patients, in 66.7% of grade II and 58.3% of grade III. This figure remained substantially unchanged at 12 and 24 months, too. Impedance monitoring indicated significantly fewer total and acid refluxes after treatment (p = 0.01). Factors predicting good outcomes were pre-procedure Hill's grade I-II, no hiatal hernia or hernia ≤2 cm (p = 0.03), absence of ineffective esophageal motility (p < 0.0001), and number of fasteners deployed (p = 0.01).

CONCLUSIONS

TIF by the EsophyX achieved lasting elimination of daily dependence on PPI in 75-80% of patients for up to 6 years. TIF seems an effective therapy for selected symptomatic GERD patients.